Smoking cessation

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

A 'No Smoking' sign

Smoking cessation is the effort to stop smoking tobacco products. Nicotine is an addictive substance, especially when taken in by inhaling tobacco smoke, probably because of the rapid absorption through the lungs. Tobacco use is one of the major causes of death worldwide, according to the World Health Organization..

Description

Research in western countries has found that approximately 3-5% of quit attempts succeed using willpower alone (Hughes et al, 2004) and clinical trials have shown that Nicotine Replacement Therapy (NRT) (see below) can double this rate to approximately 6-10% (Silagy et al, 2004). This is a small effect but is considered very worthwhile. Multi-session psychological support from a trained counselor, either individually or in groups has been shown in clinical trials to have an effect similar to that for NRT. The best chances of success can be obtained by combining medication and psychological support (see below) (USDHHS, 2000). Apart from NRT, medication that have been shown to be effective in clinical trials are: the tricyclic anti-depressant nortriptyline, bupropion (Zyban,or Quomem in some countries) and the nicotinic partial agonist, varenicline (Chantix in the US and Champix elsewhere). Thorough reviews of the evidence for all these methods of stopping are available via the Cochrane Library website Cochrane Library

There are many people and organizations touting what are claimed to be effective methods of helping smokers to stop. Any smoker thinking of paying money for such help would be well advised to ask whether the claims of success are backed up by indepedent comparative clinical trials, how the success rates have been calculated and what numbers of smokers have been included in the figures. It is very easy to make misleading claims of success rates which are not adequately supported by evidence.

A range of population level strategies such as advertising campaigns, smoking restriction policies, and tobacco taxes have been used to promote smoking cessation. Of these, raising the cost of smoking is the one that has the strongest evidence (West, 2006).

Smoking cessation will almost always lead to a longer and healthier life. Stopping in early adulthood can add up to 10 years of healthy life and stopping in one's 60s can still add 3 years of healthy life (Doll et al, 2004). Stopping smoking is also associated with better mental health and spending less of one's life with diseases of old age.

The most common short-term effects of stopping smoking are: increased irritability, depression, anxiety, restlessness, difficulty concentrating, increased appetite, constipation, mouth ulcers and increased susceptibility to upper respiratory tract infections. These mostly last for up to 4 weeks, though increased appetite typically lasts for more than 3 months. The most obvious long-term effect is weight gain (Hughes, 2007).

Statistics

• Seven percent of over-the-counter nicotine patch and gum quitters quit for at least six months

• A physician's advice to quit can increase quitting odds by 30 percent to ten percent at six months

• High intensity counseling of greater than 10 minutes can increase six month quitting rates to 22 percent when added to any quitting method, cold turkey or NRT (see Table 12)

• Quitting programs involving 91 to 300 minutes of contact time can increase six month quitting rates to 28 percent, regardless of quitting method

• Quitting programs involving 8 or more treatment sessions can increase six month quitting rates to 24.7 percent

• Bupropion (Zyban/Wellbutrin) use can generate quitting rates 13 percentage points above placebo rates at six months (see Table 25). This fact is stated as such in that all bupropion studies to date have included counseling or support elements (having their own proven efficacy) and bupropion has not been tested in an over-the-counter type setting, as have nicotine replacement therapy (NRT).

Information for smokers trying to quit

Smoking cessation services, which offer group or individual therapy can help people who want to quit. Some smoking cessation programs employ a combination of coaching, motivational interviewing, cognitive behavioral therapy, and pharmacological counseling.

Trials have shown that an effective method for quitting smoking is cognitive behaviour therapy or CBT. For example, the QUIT FOR LIFE Programme (David Marks, 1993, 2005) has produced quit rates that are 5-6 times higher than quitting by willpower alone (Marks & Sykes, 2002).

While some smokers are successful with their first attempt, many people fail several times. Many smokers find it difficult to quit, even in the face of serious smoking-related disease in themselves or close family members or friends. A serious commitment to arresting dependency upon nicotine is essential.

Some studies have concluded that those who do successfully quit smoking can gain weight. "Weight gain is not likely to negate the health benefits of smoking cessation, but its cosmetic effects may interfere with attempts to quit." (Williamson, Madans et al, 1991) Therefore, drug companies researching smoking-cessation medication often measure the weight of the participants in the study.

Tobacco smoking has a laxative effect, smoking cessation may lead to constipation, however this is by no means inevitable and is easily treated.

Major depression may challenge smoking cessation success in women. Quitting smoking is especially difficult during certain phases of the reproductive cycle, phases that have also been associated with greater levels of dysphoria, and subgroups of women who have a high risk of continuing to smoke also have a high risk of developing depression. Since many women who are depressed may be less likely to seek formal cessation treatment, practitioners have a unique opportunity to persuade their patients to quit.

Modalities

A 21mg dose Nicoderm CQ patch applied to the left arm

Techniques which can increase smokers' chances of successfully quitting are:

• Quitting "cold turkey": abrupt cessation of all nicotine use as opposed to tapering or gradual stepped-down nicotine weaning. It is the quitting method used by 80 to 90% of all long-term successful quitters.
• Smoking-cessation support and counseling is often offered over the internet, over the phone quitlines (e.g. 1-800-QUIT-NOW), or in person. One effective way to assist smokers who want to quit is through a telephone quitline which is easily available to all. Professionally run quitlines may help less dependent smokers, but those people who are more heavily dependent on nicotine should seek local smoking cessation services, where they exist, or assistance from a knowledgeable health professional, where they do not. Some evidence suggests that better results are achieved when counseling support and medication are used simultaneously. Quitting with a group of other people who want to quit is also a proven method of getting support, available through many organizations.
• Nicotine replacement therapy, NRT: pharmacological aids that are clinically proven to help with withdrawal symptoms, cravings, and urges (for example, transdermal nicotine patches, gum, lozenges, sprays, and inhalers)
• The antidepressant bupropion, marketed under the brand name Zyban®, helps with withdrawal symptoms, cravings, and urges.

Bupropion is contraindicated in epilepsy, seizure disorder; anorexia/bulimia (eating disorders), patients use of psychosis drugs (MAO inhibitors) within 14 days, patients undergoing abrupt discontinuation of ethanol or sedatives (including benzodiazepines such as Valium)

• Nicotinic receptor antagonist varenicline (Chantix®) (Champix® in the UK)
• Recently, a shot given multiple times over the course of several months, which primes the immune to produce antibodies which attach to nicotine and prevent it from reaching the brain, has shown promise in helping smokers quit. However, this approach is still in the experimental stages. [2]

Alternative techniques

Some 'alternative' techniques which have been used for smoking cessation are:

• Hypnosis clinical trials studying hypnosis as a method for smoking cessation have been inconclusive. (The Cochrane Database of Systematic Reviews 2006, Issue 3.)
• Herbal preparations such as Kava and Chamomile
• Acupuncture clinical trials have shown that acupuncture's effect on smoking cessation is equal to that of sham/placebo acupuncture. (See Cochrane Review)
• Attending a self-help group such as Nicotine Anonymous[3] and electronic self-help groups such as Stomp It Out[4]
• Laser therapy based on acupuncture principles but without the needles.
• Quit meters: Small computer programs that keep track of quit statistics such as amount of "quit-time", cigarettes not smoked, and money saved.
• Self-help books (Allen Carr, FreshStartMethod etc.) Some of these claim very high success rates but little externally verified evidence of this success exists.
• Spirituality Spiritual beliefs and practices may help smokers quit.[5]
• Smokeless tobacco: Snus is widely used in Sweden, and although it is much healthier than smoking, something which is reflected in the low cancer rates for Swedish men, there are still some concerns about its health impact. [6]
• Herbal and aromatherapy "natural" program formulations.
• Smoking reduction utensil (minitoke)
• Smoking herb substitutions (non-tobacco)[[7]]

Information for healthcare professionals

Clinical practice guidelines by the United States Preventive Service Task Force (USPSTF) in 2009 stated:

• “The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products.” (Grade A recommendation)

The USPSTF has provided good evidence that demonstrates a clear benefit in both successful smoking cessation and greater than 1 year abstinence when clinicians provide smoking cessation interventions to adult patients. These interventions include behavioral counseling (<10 minutes) and pharmacotherapy. Brief smoking cessation counseling (3 minutes) though less effective, was found to increase quit rates.

A systematic review by the Cochrane Collaboration defined brief advice from a single verbal “stop smoking” statement to counseling up to 20 minutes and cited evidence that demonstrated when “assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%.

Regarding individual studies, several have found that smoking cessation advice is not always given in primary care in patients aged 65 and older, despite the significant health benefits which can ensue in the older population.

Health professionals may follow the "five As" with every smoking patient they come in contact with:

1. Ask about smoking
2. Advise quitting
3. Assess current willingness to quit
4. Assist in the quit attempt
5. Arrange timely follow-up

See also

• Nicotine Anonymous
• Health promotion
• NicVAX
• Nicotine replacement therapy
• Tobacco cessation clinic
• Tobacco and health

References

• Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years' observations on male British doctors. Bmj 2004;328(7455):1519.
• Helgason AR, Tomson T, Lund KE, Galanti R, Ahnve S, Gilljam H. Factors related to abstinence in a telephone helpline for smoking cessation. European J Public Health 2004: 14;306-310.
• Henningfield J, Fant R, Buchhalter A, Stitzer M. "Pharmacotherapy for nicotine dependence". CA Cancer J Clin. 55 (5): 281–99, quiz 322-3, 325. PMID 16166074.CS1 maint: Multiple names: authors list (link) Full text
• Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004;99(1):29-38.
• Hutter H.P. et al. Smoking Cessation at the Workplace:1 year success of short seminars. International Archives of Occupational & Environmental Health. 2006;79:42-48.
• Marks, D.F. The QUIT FOR LIFE Programme:An Easier Way To Quit Smoking and Not Start Again. Leicester: British Psychological Society. 1993.
• Marks, D.F. & Sykes, C. M. Randomized controlled trial of cognitive behavioural therapy for smokers living in a deprived area of London: outcome at one-year follow-up

Psychology, Health & Medicine. 2005;7:17-24.

• Marks, D.F. Overcoming Your Smoking Habit. London: Robinson.2005.
• Peters MJ, Morgan LC. The pharmacotherapy of smoking cessation. Med J Aust 2002;176:486-490. Fulltext. PMID 12065013.
• Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2004(3):CD000146.
• USDHHS. Treating Tobacco Use and Dependence. Rockville, MD: Agency for Healthcare Research Quality; 2000.
• West R. Tobacco control: present and future. Br Med Bull 2006;77-78:123-36.
• Williamson, DF, Madans, J, Anda, RF, Kleinman, JC, Giovino, GA, Byers, T Smoking cessation and severity of weight gain in a national cohort N Engl J Med 1991 324: 739-745
• World Health Organization, Tobacco Free Initiative
• Zhu S-H, Anderson CM, Tedeschi GJ, et al. Evidene of real-world effectiveness of a telephone quitline$for smokers. N Engl J Med 2002;347(14):1087-93.

External links

• Helpguide.org - How to Quit Smoking
• Quit Smoking Video
• American Cancer Society Quit Tobacco Resources
• National Cancer Institution Online guide to quitting
• WhyQuit.com
• University of Wisconsin Center for Tobacco Research and Intervention
• Columbia University School of Nursing Smoking Cessation Portal
• Technique to Quit Smoking
• Stop-tabac.ch: smoking cessation website in 5 languages
• SmokeFreeMe is an online guide to quit smoking